Toe Fractures

Toe fractures account for approximately 8% to 9% of fractures. Toe fractures are relatively straightforward to treat, and the outcome is generally excellent. Hence, they are frequently managed by primary care providers. Clinicians who understand basic principles of fracture care and can recognize the occasional toe fracture that requires referral should be able to confidently manage the vast majority of closed toe fractures. In isolated settings, primary care physicians with additional experience in fracture management sometimes treat selected open toe fractures.

Toe Fractures

Anatomic Considerations

The second through fifth digits generally have three phalanges, and the first toe (and occasionally the fifth) has two. Extensor and flexor tendons insert on the proximal aspects of the middle and distal phalanges. These are occasionally injured in toe fractures. The interosseous, abductor, adductor, and flexor muscles insert at the bases of the proximal phalanges. The action of these muscles occasionally contributes to displacement of proximal fragments. Sesamoid bones may be present in the flexor tendons beneath the distal head of the metatarsals and are most frequently seen adjacent to the first metatarsal head.

Mechanism of Injury

Nearly all toe fractures result from either a stubbing injury or a heavy object being dropped on the toe. Infrequently, hyperextension of the toe results in avulsion or spiral fractures. Open toe fractures are often caused by lawnmower injuries or other sharp trauma.

Clinical Presentation

The severe pain experienced at the time of fracture often subsides, leading many patients to doubt the presence of a fracture. A dull throbbing usually follows, however, and most patients who do not seek care initially do so after 24 to 48 hours. When examined, the fractured toe usually appears swollen, and point tenderness is present at the fracture site. Ecchymosis, a subungual hematoma, or both may be present. Injuries to the nail and nail plate are commonly associated with toe fractures, and a laceration of the nail plate often indicates an open fracture. In the case of the great toe, tense swelling may be apparent, particularly if a crushing injury has occurred. Significant crushing of overlying soft tissue and subsequent necrosis and sloughing may convert a closed fracture to an open one. The neurovascular status of the toes should be documented, although nerve or arterial injury associated with toe fractures is rare except with severe displacement and lawnmower-type injuries.

Because the bones are small and tenderness is generally diffuse, it is often difficult to pinpoint or confirm a nondisplaced toe fracture on clinical grounds alone. Displaced toe fractures, on the other hand, are generally quite evident. Not enough soft tissue exists to disguise the rotation, angulation, or shortening that accompanies most displaced toe fractures.

Imaging

In most cases, anteroposterior (AP), lateral, and oblique views are necessary to diagnose toe fractures. The oblique view is often more helpful than the lateral because overlying shadows may make the lateral view difficult to interpret. Most toe fractures are nondisplaced or minimally displaced. Spiral fractures may show shortening and rotation, and transverse fractures occasionally have significant angulation. Toe fractures are frequently comminuted, particularly if the distal phalanx is involved. Two phalanges are often fractured simultaneously, and intraarticular fractures are fairly common ( Figure 16-1 ).

FIGURE 16-1

Fracture of the great toe with involvement of proximal and distal phalanges. Note that the distal phalanx fracture is comminuted with two separate fracture lines extending into the interphalangeal joint. The proximal phalanx fracture also extends into the joint.

Indications for Orthopedic Referral

Open toe fractures involving the proximal phalanx should be referred promptly, as should severe crush injuries and those with vascular compromise. Open fractures of the distal phalanx should either be referred right away or treated promptly as described below. Referral is preferable if the patient is diabetic or immunocompromised, the wound is grossly contaminated, or presentation is delayed.

The great toe plays an important weight-bearing role. Because deformity, decreased range of motion, and degenerative changes may interfere with patients’ activities, great toe fractures are much more likely than other toe fractures to require referral. Displaced intraarticular fractures of the great toe generally require internal fixation, as do great toe fractures that spontaneously become displaced when traction is released after reduction. Compared with the great toe, the lesser toes are extremely forgiving. Referral is rarely necessary unless the fracture is open or difficult to reduce. Other indications for referral (greater and lesser toes) include fracture dislocations and displaced intraarticular fractures. Nondisplaced intraarticular toe fractures heal well with conservative treatment.

7 to 10 days for intraarticular fractures or fractures requiring reduction only

Patient instruction

Persistent pain possible for several weeks or months Hard-soled shoe worn as much as possible during healing

Indications for orthopedic consult

Displaced intraarticular fractures Fracture dislocations Intraarticular fractures involving >25% of the joint Unstable displaced fracture of the first toe Open fractures of the proximal phalanges Open fracture of the distal phalanx with gross contamination or delayed treatment

SLWC, short-leg walking cast.

Nondisplaced Fractures

Most nondisplaced toe fractures can be treated by buddy taping to the adjacent toe ( Figure 16-2 ). Gauze padding should be placed between the two toes. The tape should not cover the nail beds to avoid obscuring rotational deformity until it is too late to correct the problem. After buddy taping, pain can be minimized by using ice, elevation, and appropriate medication (over-the-counter analgesics or mild narcotics for the first few days). Overzealous application of ice could potentially injure a digit, so direct contact of ice with skin should be avoided, and icing should be limited to 20 minutes per hour. Elevation should be strongly encouraged to help reduce pain and swelling.

FIGURE 16-2

Buddy taping of the second and third toes. Gauze padding is inserted between the toes to prevent maceration, and the nail beds are exposed to avoid concealing rotational deformity.

Pain control and early mobility can be greatly enhanced by having the patient wear firm-soled shoes that have had part of the top cut out to uncover the injured toe. Patients can be instructed to do this at home with a pair of shoes they do not mind sacrificing. A wooden postoperative shoe is a good alternative. Some patients require crutches initially. A subungual hematoma or nail bed injury should be managed as described in Chapter 3 .

Many fractures of the great toe require a short-leg walking cast with a toe platform ( Figure 16-3 ). Some authorities recommend this type of immobilization for better pain control in great toe fractures. Other experts favor buddy taping. Overall, a cast with a platform provides better immobilization. It is usually the preferred initial treatment for nondisplaced intraarticular fractures of the great toe and for great toe fractures that require reduction and are stable. Cast immobilization also should be considered for lesser toe fractures if buddy taping does not provide adequate pain relief.